Psychophysiology, •• (2012), ••–••. Wiley Periodicals, Inc. Printed in the USA.

Copyright © 2012 Society for Psychophysiological Research

DOI: 10.1111/j.1469-8986.2012.01445.x

BRIEF REPORT

Respiratory sinus arrhythmia and serotonin transporter promoter

gene polymorphisms: Taking a triallelic approach makes
a difference

ROMANA VULTURAR,a ADINA CHIŞ,a LOREDANA UNGUREANU,b and ANDREI C. MIUc

a
Department of Cell and Molecular Biology, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
b
Department of Dermatology, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
c
Cognitive Neuroscience Laboratory, Department of Psychology, Babeş-Bolyai University, Cluj-Napoca, Cluj, Romania

Abstract
It has been recently reported in Psychophysiology that carriers of the short allele of an insertion/deletion (ins/del) functional
polymorphism in the promoter region (5-HTTLPR) of the serotonin transporter gene may display decreased resting
respiratory sinus arrhythmia (RSA). However, this region hosts another functionally connected single-nucleotide poly-
morphism (rs25531), which should also be genotyped in order to correctly categorize the low- and high-expressing alleles
of 5-HTTLPR. The present study investigated resting RSA in an ethnically homogenous sample (N = 143) of participants
genotyped for both the ins/del and rs25531 polymorphisms in 5-HTTLPR. In contrast with the biallelic genotypes, based
only on the ins/del alleles, the triallelic 5-HTTLPR genotypes (i.e., including rs25531) showed no association with resting
RSA. Taking a triallelic approach to 5-HTTLPR is thus necessary in order to avoid false positive results.
Descriptors: 5-HTTLPR, rs25531, serotonin transporter gene, respiratory sinus arrhythmia, anxiety

It has been recently reported in Psychophysiology (Ellis, Beevers,
Hixon, & McGeary, 2011) that carriers of the low-expressing short
(S) allele of an insertion/deletion (ins/del) polymorphism in the
promoter region (5-HTT linked polymorphic region or 5-HTTLPR)
of the serotonin transporter gene (5-HTT1) may display reduced
resting respiratory sinus arrhythmia (RSA) in comparison to
homozygotes for the high-expressing long (L) allele. The ins/del
5-HTTLPR polymorphism consists of 14 (the S allele), 16 (the L
allele), or even more copies of a 20–23 base pair (bp) imperfect
repeat sequence (Ehli, Hu, Lengyel-Nelson, Hudziak, & Davies,
2012; Lesch et al., 1996). In light of the involvement of reduced
RSA in anxiety disorders and emotion dysregulation (Butler,
Wilhelm, & Gross, 2006; Porges, Doussard-Roosevelt, & Maiti,
1994; Thayer, Friedman, & Borkovec, 1996), the finding of a
genetic influence that may explain even only 5% of the variance of
RSA may contribute to our understanding of the etiology and
pathogenesis of these conditions. However, we will argue below
that RSA probably depends on a complex array of genetic influ-
This study was supported by Grant 27020/35/15.11.2011 from “I.
Haţieganu” University of Medicine and Pharmacy to the first author.
Address correspondence to: Andrei C. Miu, 37 Republicii Street,
400015 Cluj-Napoca, Romania. E-mail: andreimiu@psychology.ro
1. In accordance with gene/protein nomenclature guidelines, we will
use uppercase italic letters when referring to genes (e.g., the 5-HTT gene)
and uppercase roman letters when referring to gene products (e.g., the
5-HTT molecule).
bs_bs_banner
ences that each may contribute to a small degree to the variance of
this physiological phenotype. Moreover, recent evidence suggests
that a deficient vagal modulation of emotion interacts with central
nervous system mechanisms (e.g., an overresponsive central inhi-
bition system resulting in high trait anxiety; Beauchaine, 2001;
Brenner, Beauchaine, & Sylvers, 2005), and both are shaped by
environmental factors that can attenuate or facilitate the develop-
ment of withdrawal behaviors that characterize anxiety disorders.
This study focuses on the potential influence of a single gene (i.e.,
5-HTT) on RSA in healthy volunteers and illustrates that even this
reductionistic approach is complicated by the functional interaction
between two polymorphisms.
The recent finding of Ellis et al. (2011) is surprising from
several perspectives. First, RSA is only about half heritable, with
the rest of its variance being explained by environmental influences
(Osztovits et al., 2011; Snieder, van Doornen, Boomsma, &
Thayer, 2007). This may indicate either that the magnitude of
genetic influences is reduced or that the number of genes that
influence RSA is small. Several candidate genes have been
identified for RSA, including the b2-adrenergic receptor gene
(Matsunaga et al., 2007), the estrogen receptor a gene (Matsunaga
et al., 2010), the angiotensin converting enzyme gene (Thayer
et al., 2003), and the epidermal growth factor gene (Puttonen et al.,
2005). However, functional polymorphisms in other physiologi-
cally relevant genes failed to show an association with RSA:
several genes related to the renin-angiotensin system (Nishikino
et al., 2006), the choline transporter gene (Neumann, Lawrence,

1
2 R. Vulturar et al.
Jennings, Ferrell, & Manuck, 2005), the C-reactive protein
gene (Su et al., 2009), and the glutathione S-transferase genes
(Probst-Hensch et al., 2008). The general view that emerges from
these studies is that RSA is a quantitative phenotype, influenced by
multiple genes and their interactions with environment. However,
not all the genes that are physiologically related to RSA contribute
to its genetic variability.
5-HTTLPR is extremely relevant for anxiety disorders, mainly
because the functional genetic polymorphisms from this region
influence the brain availability of 5-HTT (Praschak-Rieder et al.,
2007; but see also Murthy et al., 2010), which is targeted by some
drugs with anxiolytic effects (i.e., selective serotonin reuptake
inhibitors [SSRI]; e.g., van der Linden, Stein, & van Balkom,
2000). A chronic reduction in RSA has been described in anxiety
disorders (Lyonfields, Borkovec, & Thayer, 1995) and therefore,
the recent finding of an association between 5-HTTLPR and RSA
(Crisan et al., 2009; Ellis et al., 2011) is theoretically appealing.
However, two previous molecular genetic studies failed to find a
significant association between 5-HTTLPR and resting RSA (Mitro
et al., 2008; Schmidt et al., 2000). In addition, another recent study
(Mueller et al., 2012) found that 5-HTTLPR was unrelated to
the square root of the mean squared differences of successive
NN intervals (RMSSD), a time domain measure derived from
electrocardiograms (ECG) that significantly correlates with RSA
(Neumann et al., 2009; Task Force of the European Society of
Cardiology and the North American Society of Pacing and Elec-
trophysiology, 1996). A possible explanation for the divergence of
these results is the relatively small sample sizes included in the
studies that found a positive association between 5-HTTLPR and
RSA (Crisan et al., 2009; Ellis et al., 2011).
An additional explanation for the divergence of the results of
previous genetic association studies on 5-HTTLPR and RSA is that
none of these studies genotyped the single-nucleotide polymor-
phism (SNP) rs25531 that is embedded in 5-HTTLPR (Hu et al.,
2006; Nakamura, Ueno, Sano, & Tanabe, 2000). This SNP involves
the substitution of an adenine to a guanine in the sixth nucleotide
within the first of two extra 20–23 bp repeats in the L allele of the
ins/del polymorphism (Hu et al., 2006; Kraft, Slager, McGrath, &
Hamilton, 2005; Nakamura et al., 2000; Wendland, Martin, Kruse,
Lesch, & Murphy, 2006). Therefore, the two resulting L alleles, LA
and LG, together with the S allele, comprise a triallelic locus (Hu
et al., 2006; Nakamura et al., 20002). The A → G substitution
creates a binding site for the transcription factor AP2, which sup-
presses transcription and equalizes the 5-HTT gene expression in
the presence of the LG and S alleles in dorsal raphe neurons (Hu
et al., 2006; Mortensen, Thomassen, Larsen, Whittemore, &
Wiborg, 1999). Therefore, the LG and S alleles are usually grouped
together because they have low and equivalent effects on 5-HTT
expression and then are compared with the LA allele. Recent studies
have shown the triallelic approach to 5-HTTLPR is essential for
correctly categorizing genotypes and identifying more reliable
associations with phenotypes such as obsessive compulsive dis-
order (Hu et al., 2006), therapeutic response to SSRI (Kraft et al.,
2005), anterior cingulate volume (Selvaraj et al., 2012), and trait
behavioral inhibition (Whisman, Richardson, & Smolen, 2011).
Therefore, it has been emphasized that the biallelic genotyping of
5-HTTLPR may bias association results (Hu et al., 2006), and
taking a triallelic approach is necessary in order to reevaluate the
2. LA and LG alleles correspond to z and m alleles in Nakamura et al.
(2000).
results of previous association studies that took the biallelic
approach to 5-HTTLPR (Wendland et al., 2006).
Therefore, the present study investigated resting RSA in a
larger, ethnically homogenous sample of healthy volunteers who
were genotyped for triallelic 5-HTTLPR (i.e., including both the
ins/del and rs25531 polymorphisms). To disentangle to potential
role of rs25531, which may explain the divergence of the previous
results, we analyzed the association between RSA and both bial-
lelic and triallelic 5-HTTLPR.
Method
Participants
One hundred forty-three participants (126 women) volunteered for
this study. Prior to study participation, written informed consent
was obtained from all the volunteers. They were all Caucasians of
Romanian descent and came from the same well-circumscribed
geographical area. Age ranged from 16 to 39 (M = 20.2 years).
None of the participants reported cardiovascular or neurological
conditions, and they were not on medication (e.g., anxiolytics,
beta-adrenergic antagonists, psychotropics). Participants were
asked to refrain from alcohol, caffeine, and smoking for at least 4 h
before the experiment. All the participants were compensated for
their time. The study followed the recommendations of Declaration
of Helsinki and was approved by the Babeş-Bolyai University
Research Council.
Genotyping
DNA was extracted from leukocytes (EDTA-anticoagulated blood)
using a Genomic DNA Extraction Kit (Fermentas, Vilnius, Lithua-
nia) and kept at -20°C. Both 5-HTTLPR and rs25531 genotyping
were performed using published protocols (Miu et al., 2012). One
of the participants carried an ultralong (i.e., >16 repeats) allele
(XL; Ehli et al., 2012).3
Physiological Assessment
ECG was recorded during 5-min baseline intervals, during which
the participants were requested to sit in a comfortable position and
quietly relax, with eyes open. We used disposable pregelled
Ag/AgCl electrodes for ECG, placed in a modified lead II configu-
ration at a sample rate of 500 samples/s and amplified using an
ECG100C Biopac module. After visual inspection of the record-
ings and editing to exclude artifacts in AcqKnowledge 3.9.0.17, all
the recordings were analyzed using Nevrokard 7.0.1 (Intellectual
Services, Ljubljana, Slovenia). RSA was derived by spectral analy-
sis of ECG, corresponding to power in the high frequency (HF)
band (0.15–0.4 Hz in adults). Respiration rate was measured using
the appropriate Biopac amplifier (RSP100C) and transducer
(TSD201). Respiration rate was included as a covariate in all analy-
ses of RSA, as recommended (Grossman, Karemaker, & Wieling,
1991). To get a more complete picture of cardiac sympathovagal
balance, we also calculated normal-to-normal (NN) intervals and
RMSSD through analysis of ECG in the time domain and spectral
power in the low frequency (LF) band (0.05–0.15 Hz; Task Force
3. In this study, the dependent variable was RSA. Considering that the
RSA measure from the participant who carried the XL allele was not an
outlier, we decided to include this measure in the present analyses.
Respiratory sinus arrhythmia and triallelic 5-HTTLPR 3

Table 1. Cardiorespiratory Measures by Biallelic and Triallelic 5-HTTLPR Genotypes

Respiration rate
(cycles/min) NN (ms) RMSSD LF (ms2) RSA (ms2)
Genotype
SS 74.89 ⫾ 2.59 746.58 ⫾ 19.94 42.25 ⫾ 7.53 733.35 ⫾ 143.41 1061.7 ⫾ 233.65
LGLG 88.5 ⫾ 3.5 925.52 ⫾ 122.82 40.32 ⫾ 28.41 723.61 ⫾ 593.24 1080 ⫾ 1036.47
SLG 74.63 ⫾ 7.19 759.61 ⫾ 33.27 37.66 ⫾ 6.02 879.53 ⫾ 398.16 967.37 ⫾ 300.38
SLA 75.4 ⫾ 2.08 748.01 ⫾ 13.23 38 ⫾ 2.9 783.35 ⫾ 89.69 1014.97 ⫾ 139.27
LALG 78.5 ⫾ 2.59 735.82 ⫾ 16.75 29.57 ⫾ 6.95 497.85 ⫾ 107.4 778.1 ⫾ 374.38
LALA 75.86 ⫾ 2.79 783.43 ⫾ 20.31 40.13 ⫾ 3.61 872.45 ⫾ 118.37 1171.34 ⫾ 205.6
LAXL 95 749.76 40.7 350.82 702.72
Biallelic genotypes
SS 77.93 ⫾ 2.37 787.29 ⫾ 18.06 38.6 ⫾ 3.31 770.3 ⫾ 98.45 1110.13 ⫾ 182.6
SL 75.33 ⫾ 2.02 749.01 ⫾ 12.43 37.95 ⫾ 2.69 790.87 ⫾ 91.35 1010.22 ⫾ 129.36
LL 74.07 ⫾ 2.48 742.46 ⫾ 18.89 42.17 ⫾ 7.04 783.4 ⫾ 142.24 1054.39 ⫾ 218.26
Triallelic genotypes (grouped)
S′S′ 75.86 ⫾ 2.79 783.43 ⫾ 20.31 40.13 ⫾ 3.61 872.45 ⫾ 118.37 1171.34 ⫾ 205.6
S′L′ 75.67 ⫾ 1.91 746.95 ⫾ 12.16 37.27 ⫾ 2.72 758.52 ⫾ 82.86 994.38 ⫾ 130.8
L′L′ 75.55 ⫾ 2.43 758.74 ⫾ 17.94 41.18 ⫾ 5.76 763.61 ⫾ 134.05 1042.84 ⫾ 185.79

Note. Values in cells are mean ⫾ one standard error of the mean (with the exception of LAXL, for which only the mean from the only participant with this
genotype is reported). NN: normal-to-normal intervals; RMSSD: square root of the mean squared differences of successive NN intervals; LF: power in the
low frequency band; RSA (or HF): respiratory sinus arrhythmia.

of the European Society of Cardiology and the North American
Society of Pacing and Electrophysiology, 1996).
Results
Genotypes
The frequency of alleles was 0.88 for S, 0.97 for LA, 0.12 for LG
and 0.006 for XL. The distribution of the 5-HTTLPR ins/del and
rs25531 genotypes was as follows: 28 SS, 2 LGLG, 8 SLG, 6 LALG,
63 SLA, 35 LALA, and 1 LAXL. On the basis of the biallelic
5-HTTLPR, the genotypes were categorized into 28 SS, 61 SL, and
44 LL. These genotypes were in Hardy–Weinberg equilibrium,
c2 = 0.64, n.s.
On the basis of the triallelic 5-HTTLPR, the genotypes were
categorized into 38 carriers of two low-expressing alleles (i.e., SS,
LGLG, SLG), labeled S′S′ for simplicity; 69 carriers of one low-
expressing allele (i.e., LALG, SLA), labeled S′L′; and 36 carriers of
two high-expressing alleles (i.e., LALA, LAXL), labeled L′L′. These
genotypes were in Hardy–Weinberg equilibrium, c2 = 0.17, n.s.
In comparison to the biallelic classification, 16 participants
(11.18%) were reclassified according to the triallelic genotypes:
2 participants (1.39%) had been categorized as high-expressing LL
and were reclassified as low-expressing S′S′, 8 participants (5.6%)
had been categorized as SL and were reclassified as low-expressing
S′S′, and 6 participants (4.19%) had been categorized as high-
expressing LL and were reclassified as intermediate-expressing
S′L′.
Biallelic Genotypes and Respiratory Sinus Arrhythmia
An analysis of covariance (ANCOVA) with the biallelic
5-HTTLPR genotype (SS vs. SL vs. LL) as the between-subject
factor and respiration rate as the covariate found a marginally
significant effect on RSA, F(2,140) = 3.05, p = .08, partial
h2 = .02. To test a model in which the S allele was dominant, we
collapsed together the SS and SL groups and compared between the
S carriers and LL groups. We found a statistically significant effect
of genotype on RSA, F(2,140) = 3.19, p = .05, partial h2 = .02,4
with lower RSA in S carriers compared to LL homozygotes. We
cross-validated these results by splitting the sample in two random
halves (n = 71) and running the analyses in each subsample. The
effect of biallelic 5-HTTLPR remained significant in only one of
the subsamples, with a similarly small effect size.
There were no significant effects on NN, RMSSD, and LF.
Triallelic Genotypes and Respiratory Sinus Arrhythmia
Table 1 presents cardiorespiratory measures by triallelic 5-
HTTLPR genotypes. An ANCOVA with the triallelic 5-HTTLPR
genotype (S′S′ vs. S′L′ vs. L′L′) as the between-subject factor and
respiration rate as the covariate indicated no significant effect on
RSA, F(2,140) = 0.31, p = .72, partial h2 = .00. The comparison of
the S′-allele carriers (after collapsing together S′S′ and S′L′) and
L′L′ also found no significant effect of triallelic 5-HTTLPR on
RSA, F(2,140) = 0.59, p = .44, partial h2 = .00. The same pattern of
results was replicated in two randomly selected subsamples.
There were no significant effects on the other cardiovascular
measures.
Discussion
Following the recommendation to reevaluate the results of previous
studies that took a biallelic approach to 5-HTTLPR (Hu et al., 2006;
Wendland et al., 2006), we tried to replicate the association of
5-HTTLPR and RSA in a sample of healthy volunteers who were
genotyped for both the ins/del and rs25531 polymorphisms. The
biallelic 5-HTTLPR genotype had a small yet significant effect
on RSA, with carriers of the S allele displaying reduced RSA
4. Considering that we found a significant effect of 5-HTTLPR on trait
anxiety due to physical threat from the Endler Multidimensional Anxiety
Scales (Endler, Edwards, & Vitelli, 1991; data not shown), we also included
this score as a covariate in the analyses of RSA. When we controlled for
this trait anxiety score, the effect of biallelic 5-HTTLPR on RSA became
nonsignificant.
4 R. Vulturar et al.
compared to the LL homozygotes. However, this effect was cross-
validated in only one of the randomly selected halves of the present
sample, which was identical in size (n = 71) to that included in the
study of Ellis et al. (2011). Moreover, after reclassifying the carri-
ers of the low-expressing LG allele (11.18% of the sample) into the
S′S′ or S′L′ groups, the positive association of 5-HTTLPR and RSA
became nonsignificant. Overall, the present results indicate that
the relatively small sample size and the incorrect classification of
the LG allele as high-expressing may explain te previous positive
association between biallelic 5-HTTLPR and resting RSA (Ellis
et al., 2011).
The present results are in line with other studies that compared
between biallelic and triallelic 5-HTTLPR genotyping and found
significant differences between these approaches. For instance,
Kraft et al. (2005) reported that the ins/del 5-HTTLPR polymor-
phism alone was not associated with SSRI treatment response, but
that rs25531 alone and together with the ins/del polymorphism
influenced the psychopharmacological response to SSRI. Another
recent study (Selvaraj et al., 2012) found that triallelic 5-HTTLPR
was reliably associated with reduced gray matter volume only in
the anterior cingulate in contrast with previous reports from smaller
samples genotyped only for biallelic 5-HTTLPR, which had found
many more positive associations with gray matter volume in nono-
verlapping brain areas. A third example came from the study of
Whisman et al. (2011), which compared the associations of the
biallelic and triallelic 5-HTTLPR and trait behavioral inhibition.
These authors found that only the triallelic classification of geno-
types revealed that carriers of the S or LG alleles displayed
increased behavioral inhibition in comparison to the LA homozy-
gotes (Whisman et al., 2011). Together with the present results,
these studies underscore the importance of taking a triallelic
approach to 5-HTTLPR in order to reduce the bias associated with
incorrectly classifying LG alleles as high-expressing. This may be
particularly important in studies that include small sample sizes,
in which Caucasians and African Americans (with higher LG fre-
quency: 0.14–0.24; see Hu et al., 2006) predominate. The present
study included an ethnically homogenous sample of Caucasian
participants selected from the same circumscribed geographical
area. Whereas the ethnic homogeneity of our sample allowed us to
exclude the confounding effect of ethnic stratification and contrib-
uted to the validity of these results, it also limited their generality.
References
Beauchaine, T. P. (2001). Vagal tone, development, and Gray’s motivational
theory: Toward an integrated model of autonomic nervous system
functioning in psychopathology. Development and Psychopathology,
13, 183–214. doi:10.1017/S0954579401002012
Brenner, S. L., Beauchaine, T. P., & Sylvers, P. D. (2005). A comparison of
psychophysiological and self-report measures of behavioral approach
and behavioral inhibition. Psychophysiology, 42, 108–115. doi:10.1111/
j.1469-8986.2005.00261.x
Buckland, P. R. (2001). Genetic association studies of alcoholism: Prob-
lems with the candidate gene approach. Alcohol and Alcoholism, 36,
99–103. doi:10.1093/alcalc/36.2.99
Butler, E. A., Wilhelm, F. H., & Gross, J. J. (2006). Respiratory sinus
arrhythmia, emotion, and emotion regulation during social inter-
action. Psychophysiology, 43, 612–622. doi:10.1111/j.1469-8986.2006.
00467.x
Crisan, L. G., Pana, S., Vulturar, R., Heilman, R. M., Szekely, R., Druga,
B., . . . Miu, A. C. (2009). Genetic contributions of the serotonin trans-
porter to social learning of fear and economic decision making. Social
Cognitive and Affective Neuroscience, 4, 399–408. doi:10.1093/scan/
nsp019
Future studies might try to replicate the comparison of biallelic
versus triallelic 5-HTTLPR genotypes in more ethnically diverse
samples, with appropriate control of ethnic stratification.
This study included a larger sample size compared to previous
genetic association studies on 5-HTTLPR and RSA (Crisan et al.,
2009; Ellis et al., 2011). However, even this sample size may have
been too small if the effect of this genetic polymorphism on RSA
was small. Moreover, guidelines for genetic association studies
recommend larger samples (e.g., N = 400–700; e.g., Buckland,
2001). Therefore, even the present results should be interpreted
with some caution until results on larger samples are published in
research reports or meta-analyses. Future studies might also inves-
tigate the influence of 5-HTTLPR on RSA change (i.e., vagal sup-
pression) during mental stress in light of the observation from twin
studies that RSA shows higher heritability when measured during
stress (De Geus, Kupper, Boomsma, & Snieder, 2007). Such a
study is currently underway in our laboratory.
These results have implications that extend to many genetic
associations studies. First, observations of associations with small
effect sizes, in small samples, should be taken with caution. Con-
sidering that large sample sizes may often be difficult to gather,
findings from small genetic association studies should be consid-
ered preliminary until they are replicated in meta-analyses. If a
genetic association is replicated, but it has a small effect size, it
should not be discarded. Complex phenotypes such as RSA are
probably influenced by many genetic polymorphisms, and the
effect of each polymorphism is likely to be small. However, the
present results illustrate that false positive results may indeed be
reported in studies that genotype only one of two functionally
connected polymorphisms, particularly if the observations are
based on small samples.
In conclusion, these results showed that 5-HTTLPR had no
influence on resting RSA and highlight the necessity of taking a
triallelic approach to 5-HTTLPR. Because the S, LG, and LA alleles
were functionally characterized and several genetic association
studies, including this one, have shown that biallelic 5-HTTLPR
genotyping significantly biases results, we believe that there is no
justification to delay the general application of triallelic 5-HTTLPR
genotyping in future genetic association studies. Any delay might
increase the proportion of false-positive results and inconsistencies
in the literature.
De Geus, E. J., Kupper, N., Boomsma, D. I., & Snieder, H. (2007). Bivari-
ate genetic modeling of cardiovascular stress reactivity: Does stress
uncover genetic variance? Psychosomatic Medicine, 69, 356–364.
doi:10.1097/PSY.0b013e318049cc2d
Ehli, E. A., Hu, Y., Lengyel-Nelson, T., Hudziak, J. J., & Davies,
G. E. (2012). Identification and functional characterization of three
novel alleles for the serotonin transporter-linked polymorphic
region. Molecular Psychiatry, 17, 185–192. doi:10.1038/mp.2010.
130
Ellis, A. J., Beevers, C. G., Hixon, J. G., & McGeary, J. E. (2011). Serot-
onin transporter promoter region (5-HTTLPR) polymorphism predicts
resting respiratory sinus arrhythmia. Psychophysiology, 48, 923–926.
doi:10.1111/j.1469-8986.2010.01154.x
Endler, N. S., Edwards, J. M., & Vitelli, R. (1991). Endler Multidimen-
sional Anxiety Scales (EMAS): Manual. Los Angeles, CA: Western
Psychological Services.
Grossman, P., Karemaker, J., & Wieling, W. (1991). Prediction of tonic
parasympathetic cardiac control using respiratory sinus arrhythmia: The
need for respiratory control. Psychophysiology, 28, 201–216.
doi:10.1111/j.1469-8986.1991.tb00412.x
Respiratory sinus arrhythmia and triallelic 5-HTTLPR
Hu, X. Z., Lipsky, R. H., Zhu, G., Akhtar, L. A., Taubman, J., Greenberg,
B. D., . . . Goldman, D. (2006). Serotonin transporter promoter gain-of-
function genotypes are linked to obsessive-compulsive disorder. Ameri-
can Journal of Human Genetics, 78, 815–826. doi:10.1086/503850
Kraft, J. B., Slager, S. L., McGrath, P. J., & Hamilton, S. P. (2005).
Sequence analysis of the serotonin transporter and associations with
antidepressant response. Biological Psychiatry, 58, 374–381. doi:
10.1016/j.biopsych.2005.04.048
Lesch, K. P., Bengel, D., Heils, A., Sabol, S. Z., Greenberg, B. D., Petri, S.,
. . . Murphy, D. L. (1996). Association of anxiety-related traits with
a polymorphism in the serotonin transporter gene regulatory region.
Science, 274, 1527–1531. doi:10.1126/science.274.5292.1527
Lyonfields, J., Borkovec, T. D., & Thayer, J. F. (1995). Vagal tone in
generalized anxiety disorder and the effects of aversive imagery and
worrisome thinking. Behavior Therapy, 26, 457–466. doi:10.1016/
S0005-7894(05)80094-2
Matsunaga, T., Gu, N., Yamazaki, H., Adachi, T., Yasuda, K., Moritani, T.,
. . . Nonaka, M. (2010). Association of estrogen receptor-alpha gene
polymorphisms with cardiac autonomic nervous activity in healthy
young Japanese males. Clinica Chimica Acta, 411, 505–509.
doi:10.1016/j.cca.2009.12.028
Matsunaga, T., Yasuda, K., Adachi, T., Gu, N., Yamamura, T., Moritani, T.,
. . . Tsuda, K. (2007). Association of beta-adrenoceptor polymorphisms
with cardiac autonomic modulation in Japanese males. American Heart
Journal, 154, 759–766. doi:10.1016/j.ahj.2007.03.053
Mitro, P., Mudrakova, K., Mickova, H., Dudas, J., Kirsch, P., & Valocik, G.
(2008). Hemodynamic parameters and heart rate variability during a tilt
test in relation to gene polymorphism of renin-angiotensin and serotonin
system. Pacing and Clinical Electrophysiology, 31, 1571–1580.
doi:10.1111/j.1540-8159.2008.01228.x
Miu, A. C., Crisan, L. G., Chis, A., Ungureanu, L., Druga, B., & Vulturar,
R. (2012). Somatic markers mediate the effect of serotonin transporter
gene polymorphisms on Iowa Gambling Task. Genes, Brain and
Behavior, 11, 398–403. doi:10.1111/j.1601-183X.2012.00774.x
Mortensen, O. V., Thomassen, M., Larsen, M. B., Whittemore, S. R., &
Wiborg, O. (1999). Functional analysis of a novel human serotonin
transporter gene promoter in immortalized raphe cells. Molecular Brain
Research, 68, 141–148. doi:10.1016/S0169-328X(99)00083-2
Mueller, A., Strahler, J., Armbruster, D., Lesch, K. P., Brocke, B., &
Kirschbaum, C. (2012). Genetic contributions to acute autonomic stress
responsiveness in children. International Journal of Psychophysiology,
83, 302–308. doi:10.1016/j.ijpsycho.2011.11.007
Murthy, N. V., Selvaraj, S., Cowen, P. J., Bhagwagar, Z., Riedel, W. J.,
Peers, P., . . . Grasby, P. M. (2010). Serotonin transporter polymor-
phisms (SLC6A4 insertion/deletion and rs25531) do not affect the
availability of 5-HTT to [11C] DASB binding in the living human brain.
NeuroImage, 52, 50–54. doi:10.1016/j.neuroimage.2010.04.032
Nakamura, M., Ueno, S., Sano, A., & Tanabe, H. (2000). The human
serotonin transporter gene linked polymorphism (5-HTTLPR) shows
ten novel allelic variants. Molecular Psychiatry, 5, 32–38. doi:10.1038/
sj.mp.4000698
Neumann, S. A., Lawrence, E. C., Jennings, J. R., Ferrell, R. E., & Manuck,
S. B. (2005). Heart rate variability is associated with polymorphic
variation in the choline transporter gene. Psychosomatic Medicine, 67,
168–171. doi:10.1097/01.psy.0000155671.90861.c2
Neumann, S. A., Tingley, W. G., Conklin, B. R., Shrader, C. J., Peet, E.,
Muldoon, M. F., . . . Manuck, S. B. (2009). AKAP10 (I646V) functional
polymorphism predicts heart rate and heart rate variability in apparently
healthy, middle-aged European-Americans. Psychophysiology, 46,
466–472. doi:10.1111/j.1469-8986.2009.00802.x
Nishikino, M., Matsunaga, T., Yasuda, K., Adachi, T., Moritani, T.,
Tsujimoto, G., . . . Aoki, N. (2006). Genetic variation in the renin-
angiotensin system and autonomic nervous system function in young
healthy Japanese subjects. Journal of Clinical Endocrinology &
Metabolism, 91, 4676–4681. doi:10.1210/jc.2006-0700
Osztovits, J., Horvath, T., Littvay, L., Steinbach, R., Jermendy, A., Tarnoki,
A., . . . Jermendy, G. (2011). Effects of genetic vs. environmental
5
factors on cardiovascular autonomic function: A twin study. Diabetic
Medicine, 28, 1241–1248. doi:10.1111/j.1464-5491.2011.03363.x
Porges, S. W., Doussard-Roosevelt, J. A., & Maiti, A. K. (1994). Vagal tone
and the physiological regulation of emotion. Monographs of the Society
for Research in Child Development, 59, 167–186. doi:10.2307/1166144
Praschak-Rieder, N., Kennedy, J., Wilson, A. A., Hussey, D., Boovariwala,
A., Willeit, M., . . . Meyer, J. H. (2007). Novel 5-HTTLPR allele asso-
ciates with higher serotonin transporter binding in putamen: A [(11)C]
DASB positron emission tomography study. Biological Psychiatry, 62,
327–331. doi:10.1016/j.biopsych.2006.09.022
Probst-Hensch, N. M., Imboden, M., Felber Dietrich, D., Barthelemy, J. C.,
Ackermann-Liebrich, U., Berger, W., . . . Schwartz, J. (2008). Glutath-
ione S-transferase polymorphisms, passive smoking, obesity, and heart
rate variability in nonsmokers. Environmental Health Perspectives, 116,
1494–1499. doi:10.1289/ehp.11402
Puttonen, S., Keltikangas-Jarvinen, L., Elovainio, M., Kivimaki, M., Rontu,
R., & Lehtimaki, T. (2005). Epidermal growth factor A61G polymor-
phism and cardiac autonomic control in adults. Progress in Neuro-
Psychopharmacology and Biological Psychiatry, 29, 702–707.
doi:10.1016/j.pnpbp.2005.04.017
Schmidt, N. B., Storey, J., Greenberg, B. D., Santiago, H. T., Li, Q., &
Murphy, D. L. (2000). Evaluating gene ¥ psychological risk factor
effects in the pathogenesis of anxiety: A new model approach. Journal
of Abnormal Psychology, 109, 308–320. doi:10.1037//0021-843X.
109.2.308
Selvaraj, S., Godlewska, B. R., Norbury, R., Bose, S., Turkheimer, F.,
Stokes, P., . . . Cowen, P. J. (2012). Decreased regional gray matter
volume in S′ allele carriers of the 5-HTTLPR triallelic polymorphism.
Molecular Psychiatry, 16, 471, 472–473. doi:10.1038/mp.2010.112
Snieder, H., van Doornen, L. J., Boomsma, D. I., & Thayer, J. F. (2007).
Sex differences and heritability of two indices of heart rate dynamics:
A twin study. Twin Research and Human Genetics, 10, 364–372.
doi:10.1375/twin.10.2.364
Su, S., Lampert, R., Zhao, J., Bremner, J. D., Miller, A., Snieder, H., . . .
Vaccarino, V. (2009). Pleiotropy of C-reactive protein gene polymor-
phisms with C-reactive protein levels and heart rate variability in
healthy male twins. American Journal of Cardiology, 104, 1748–1754.
doi:10.1016/j.amjcard.2009.07.063
Task Force of the European Society of Cardiology and the North
American Society of Pacing and Electrophysiology. (1996). Heart rate
variability. Standards of measurement, physiological interpretation,
and clinical use. European Heart Journal, 17, 354–381. doi:10.1093/
oxfordjournals.eurheartj.a014868
Thayer, J. F., Friedman, B. H., & Borkovec, T. D. (1996). Autonomic
characteristics of generalized anxiety disorder and worry. Biological
Psychiatry, 39, 255–266. doi:10.1016/0006-3223(95)00136-0
Thayer, J. F., Merritt, M. M., Sollers, J. J., 3rd, Zonderman, A. B., Evans,
M. K., Yie, S., & Abernethy, D. R. (2003). Effect of angiotensin-
converting enzyme insertion/deletion polymorphism DD genotype on
high-frequency heart rate variability in African Americans. American
Journal of Cardiology, 92, 1487–1490. doi:10.1016/j.amjcard.2003.
08.069
van der Linden, G. J., Stein, D. J., & van Balkom, A. J. (2000). The efficacy
of the selective serotonin reuptake inhibitors for social anxiety disorder
(social phobia): A meta-analysis of randomized controlled trials.
International Clinical Psychopharmacology, 15(Suppl 2), S15–23.
Wendland, J. R., Martin, B. J., Kruse, M. R., Lesch, K. P., & Murphy, D. L.
(2006). Simultaneous genotyping of four functional loci of human
SLC6A4, with a reappraisal of 5-HTTLPR and rs25531. Molecular
Psychiatry, 11, 224–226. doi:10.1038/sj.mp.4001789
Whisman, M. A., Richardson, E. D., & Smolen, A. (2011). Behavioral
inhibition and triallelic genotyping of the serotonin transporter promoter
(5-HTTLPR) polymorphism. Journal of Research in Personality, 45,
706–709. doi:10.1016/j.jrp.2011.08.009
(Received February 27, 2012; Accepted June 14, 2012)